NCLEX NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. Asepsis is defined as ________________.
- A. the absence of all microorganisms
- B. the absence of disease-causing germs
- C. a urinary infection
- D. a pathogenic infection
Correct answer: the absence of disease-causing germs
Rationale: Asepsis is defined as the absence of disease-causing germs. It is surgical asepsis that is defined as the absence of all microorganisms, including spores. A pathogenic infection is an invasion of the body by a pathogen, or disease-causing germ, and a urinary infection is only one type of infection.
2. What approach should the nurse use when a manipulative client who uses acting-out behaviors asks the nurse to talk while the nurse is orienting a new client to the unit?
- A. Suggest that the client requesting attention speak with another staff member.
- B. Leave the new client, saying, 'I’ll talk with the other client until things calm down.'
- C. Introduce the two clients and suggest that the client join them on a tour of the facility.
- D. Say to the interrupting client, 'I’ll be back to talk with you after I orient this new client.'
Correct answer: Say to the interrupting client, 'I’ll be back to talk with you after I orient this new client.'
Rationale: The nurse should respond to the manipulative client who uses acting-out behaviors by setting realistic limits on behavior without rejecting the client. Therefore, the correct approach is to say to the interrupting client, 'I’ll be back to talk with you after I orient this new client.' This response acknowledges the client's request while prioritizing the needs of the new client and setting appropriate boundaries. Choices A, B, and C are incorrect. Suggesting that the client speak with another staff member would be a rejection of the client, not the behavior. Leaving the new client to attend to the manipulative client would encourage further manipulation and disrupt the orientation process for the new client. Introducing the two clients and suggesting a tour is inconsistent with setting limits and does not address the manipulative behavior being displayed.
3. Based on Mr. C's assessment, which of the following nursing interventions is most appropriate?
- A. Elevate the lower extremities to 45 degrees to promote venous return
- B. Place Mr. C in the Trendelenburg position
- C. Administer total parenteral nutrition
- D. Monitor urine output
Correct answer: Monitor urine output
Rationale: In the context of Mr. C's assessment, the most appropriate nursing intervention is to monitor urine output. A client in hypovolemic shock may experience decreased urine output due to poor kidney perfusion. By monitoring urine output, the nurse can assess renal function and fluid status. Administering total parenteral nutrition (Choice C) is not indicated based on the information provided, as the priority is to stabilize the client's condition. Elevating the lower extremities (Choice A) may be helpful in some cases but is not the priority in this situation. Placing Mr. C in the Trendelenburg position (Choice B) is contraindicated in hypovolemic shock as it can worsen venous return and compromise cardiac output.
4. A group of nurses who work on the quality assurance council of a unit have gathered to discuss ideas about how to educate their coworkers about Joint Commission requirements. Each of the nurses gives ideas, which are listed together without initial criticism. Eventually, all ideas on the list will be discussed as to their validity. This activity is known as:
- A. Optimizing
- B. Satisficing
- C. Brainstorming
- D. Centralizing
Correct answer: Brainstorming
Rationale: Brainstorming is the process in which group members generate ideas without immediate criticism or evaluation. This allows for a free flow of creative suggestions. The ideas are then listed together for consideration and discussion of their validity at a later stage. Optimizing, although related to improving efficiency, does not specifically address the initial idea generation process. Satisficing refers to accepting a satisfactory or 'good enough' solution rather than seeking the best possible option, which is not reflective of the scenario described. Centralizing typically refers to consolidating decision-making authority rather than the collaborative idea generation process seen in brainstorming.
5. What would a healthcare professional expect to observe while assessing the growth of children during their school-age years?
- A. Decreasing amounts of body fat and muscle mass
- B. Little change in body appearance from year to year
- C. Progressive height increase of 4 inches each year
- D. Yearly weight gain of about 5.5 pounds per year
Correct answer: Yearly weight gain of about 5.5 pounds per year
Rationale: During school-age years, children typically gain about 5.5 pounds per year and increase in height by about 2 inches annually. This steady growth pattern is expected between ages 2 to 10 years. Choice A is incorrect as children at this stage are expected to gain weight and grow in height. Choice B is incorrect as there should be noticeable changes in body appearance due to growth. Choice C is incorrect as a progressive height increase of 4 inches each year is not typical during the school-age years.
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